COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS CUYAHOGA COUNTY, OHIO _________________________________________ Plaintiff (P) _________________________________________ Address _________________________________________ City, State, Zip Code Marital Residence: Yes No : : : : : : : : Judge: ___________________________________ Case Number: ___________________________________ _________________________________________ Day Time Telephone Number _________________________________________ Attorney _________________________________________ Attorney Address _________________________________________ Attorney Telephone vs. FINANCIAL DISCLOSURE STATEMENT WITH AFFIDAVIT OF PROPERTY, INCOME & EXPENSES _________________________________ (Your Name) : _________________________________________ Defendant (D) _________________________________________ Address _________________________________________ City, State, Zip Code Marital Residence: Yes No : : Plaintiff (P) Defendant (D) : _________________________________________ Day Time Telephone Number _________________________________________ Attorney _________________________________________ Attorney Address _________________________________________ Attorney Telephone : : Date of Marriage: : Date of Separation ____________________________ : ____________________________ Your Date of Birth: ____________________________ THIS STATEMENT MUST BE COMPLETED IN FULL AND FILED WITH THE COURT SEVEN (7) DAYS PRIOR TO THE FIRST PRETRIAL CONFERENCE, AND UPDATED THEREAFTER IN ACCORDANCE WITH LOCAL RULE OR AS ORDERED BY THE COURT. A COPY OF THIS STATEMENT SHALL ALSO BE SERVED ON THE OPPOSING PARTY OR HIS/HER COUNSEL. A SUBSTANTIAL AND WILLFUL FAILURE BY A PARTY TO DISCLOSE FULLY ALL OF HIS/HER ASSETS, DEBTS, INCOME AND EXPENSES MAY SUBJECT THE PARTY TO MONETARY SANCTIONS PURSUANT TO R.C. 3105.171(E)(5), INCLUDING COMPENSATION TO THE OFFENDED SPOUSE OR A GREATER OR DISTRIBUTIVE AWARD OF MARITAL PROPERTY UP TO THREE TIMES THE VALUE OF THE NON-DISCLOSED ASSET, ETC. Financial Statement (Revised 8/2015) Initial: ________ Page 1 of 9 American LegalNet, Inc. www.FormsWorkFlow.com I. PROPERTY List ALL OF YOUR PROPERTY AND DEBTS, those of your partner, and joint property and debts. Do not leave any category blank. For each item, if none, write "NONE." If you do not know exact figures for any item, give your best estimate and write "EST." A. Real estate interests: PLEASE STATE WHETHER ANY LEGAL ACTIONS ARE PENDING (i.e. FORECLOSURES, ETC.) If more space is needed, attach extra pages. See additional pages: YES Address (Check box if legal action is pending) Titled to (P), (D), or Both (Check box) (P) (D) Both $ Present Fair Market Value Names & Addresses of Mortgage/Lien Holders Mortgage/Lien Balance Due Monthly Mortgage/Lien Payments $ $ $ $ $ A. $ $ B. (P) (D) Both $ $ $ TOTALS $ B. Other assets: PLEASE STATE WHETHER ANY LEGAL ACTIONS ARE PENDING. If more space is needed, attach extra pages. See additional pages: Titled to: (P), (D) or both) In Possession of (P) or (D) $ Check box if subject of pending legal action. $ $ $ $ $ $ $ $ $ $ $ $ $ $ YES Balance on Liens/Loans (if any) Monthly Payment on Liens/Loans Category A. Vehicles Description Include automobiles, trucks, motorcycles, boats, motor homes, etc. Identify year, make and name of Lien Holder Present Fair Market Value B. Financial Accounts Check box if subject of pending legal action. Include checking, savings, CDs, POD accounts, money market accounts, etc. $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ C. Pensions & Retirement Plans Check box if subject of pending legal action. Identify each plan, including profit-sharing, IRAs, 401(k)s, etc. $ $ $ $ $ $ $ $ $ $ $ $ D. Publicly Held Stocks, Bonds, Securities & Mutual Funds Check box if subject of pending legal action. Identify name of company, type of shares, and number of shares. $ $ $ $ Initial: ________ $ $ $ $ $ $ $ $ Page 2 of 9 American LegalNet, Inc. www.FormsWorkFlow.com Financial Statement (Revised 8/2015) Category E. Closely Held Business Interests Check box if subject of pending legal action. Description Identify business, type of ownership and percentage of stock Titled to: (P), (D) or both) Present Fair Market Value Balance on Liens/Loans (if any) Monthly payment on Liens/Loans $ $ $ $ $ Specify the amount of any cash surrender value. $ Check box if subject of pending legal action. $ $ $ $ $ $ $ $ $ $ $ $ $ $ F. Life insurance Identify policy, beneficiary and whether a term life or whole life policy $ $ $ $ $ $ $ $ $ $ G. Safe Deposit box(es) Check box if subject of pending legal action. Give location and describe contents $ $ $ Include collections, rare books, stamps, guns, antiques, art objects, computers machinery, personal injury/workers compensation claims, promissory notes, loans to others, tax refunds due, interests in estates or trusts, franchises, copyrights, etc. $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Attach detailed inventory if more space is needed See attached inventory $ $ $ $ $ $ $ $ $ $ Present Fair Market Value $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ H. Miscellaneous Assets Check box if subject of pending legal action. I. Furniture and Appliances In your possession In spouse's possession TOTALS $ $ $ $ J. Transferred Assets Explanation: List the name and address of any person (other than your spouse and creditors listed on this affidavit) to whom you have given money or property exceeding $100.00 in value in the past 12 months. Name and Address of Transferee Reason for Transfer Check box if subject of pending legal action. $ $ $ $ TOTAL Financial Statement (Revised 8/2015) Initial: ________ $ Page 3 of 9 American LegalNet, Inc. www.FormsWorkFlow.com C. Unsecured Debts: If you do not know exact figures for any item, give your best estimate and write "EST." List ALL UNSECURED DEBTS INCLUDING CREDIT CARDS (SECURED DEBTS SHOULD BE LISTED BESIDE THE ASSET SECURING THAT DEBT IN SECTIONS A & B ON PAGES 2 AND 3.) If more space is needed, attach extra pages. See additional pages: YES Name of Creditor Purpose of Debt Last 4 digits of account # In name of (P), (D) or Joint Used by (P), (D) or Both $ $ $ $ $ $ $ $ $ TOTALS $ $ Total Balance (principle and interest) Monthly Payment $ $ $ $ $ $ $ $ $ $ $ D. Separate Property Claims as defined in Ohio Revised Code §3105.17(A)(6)(a) If more space is needed, attach extra pages. See additional pages: YES Category Inheritances Property Owned Before Marriage Passive Income and Appreciation Property Acquired after a Legal Separat